HESI LPN
HESI Fundamentals Exam
1. A client is being taught about medications at discharge. Which statement should the nurse identify as an indication that the client understands the instructions?
- A. I can open the time-release capsule with the beads in it and sprinkle them on my oatmeal.
- B. If I am having difficulty swallowing, I will add the liquid medication to a prepared package of pudding.
- C. I can crush the enteric-coated pill if needed.
- D. I will eat two crackers with the pain pills.
Correct answer: B
Rationale: The correct answer is B. Adding liquid medication to pudding can help with swallowing difficulties, demonstrating understanding of the instructions. Options A and C are incorrect as altering time-release capsules and enteric-coated pills is not recommended in medication administration. Option A is incorrect as time-release capsules should not be opened and sprinkled on food, affecting their efficacy. Option C is incorrect as crushing enteric-coated pills can affect their absorption. Option D is unrelated to medication administration and does not demonstrate understanding of the instructions.
2. A nurse is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
- A. Use the complete name of the medication magnesium sulfate
- B. Maintain the space between the numerical dose and the unit of measure
- C. Note the dosage of insulin in units
- D. Use 'subcut' for indicating a subcutaneous injection
Correct answer: A
Rationale: The correct answer is A. The Institute for Safe Medication Practices recommends using the complete medication name magnesium sulfate when documenting medications to prevent misinterpretation. Choice B is incorrect because spaces should be maintained between the numerical dose and unit of measure for clarity. Choice C is incorrect as the standard notation for insulin dosage is in units, not using the letter U. Choice D is incorrect as the abbreviation for subcutaneous injection is commonly written as 'subcut' or 'subcutaneous,' not as SC.
3. A client with a history of falls is under the care of a nurse. Which of the following actions should be the nurse’s priority?
- A. Complete a fall-risk assessment.
- B. Educate the client and family about fall risks.
- C. Eliminate safety hazards from the client’s environment.
- D. Ensure the client uses assistive aids in their possession.
Correct answer: C
Rationale: The nurse's priority should be to eliminate safety hazards from the client's environment as it directly reduces the risk of falls. Addressing environmental hazards is an immediate and crucial step in preventing falls. While completing a fall-risk assessment is important to understand the client's risk factors, educating the client and family about fall risks is essential for prevention, and ensuring the use of assistive aids is crucial for safety, eliminating safety hazards takes precedence as it directly mitigates the risk of falls.
4. A 3-year-old child has had multiple tooth extractions while under general anesthesia. The client returns from the post-anesthesia care unit crying but awake. Which approach is likely to be successful?
- A. Examine the mouth first
- B. Reassure the child
- C. Examine the mouth last
- D. Offer a pacifier
Correct answer: C
Rationale: In this scenario, it is crucial to prioritize the comfort of the child. By examining the mouth last, discomfort is minimized, and the child is given the opportunity to settle down. Choosing to examine the mouth first may escalate the distress of the child further. While reassuring the child is important, in this case, addressing the physical discomfort before providing emotional reassurance is more effective. Offering a pacifier may provide some comfort, but addressing the immediate physical discomfort by examining the mouth last is the most appropriate action to help the child settle down after the procedure.
5. A healthcare professional is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the healthcare professional take?
- A. Place the bladder of the cuff over the posterior aspect of the thigh
- B. Use a smaller cuff designed for lower extremities
- C. Place the cuff around the client's ankle
- D. Ensure the cuff is positioned above the knee
Correct answer: A
Rationale: When measuring blood pressure in the lower extremity, the bladder of the cuff should be placed over the posterior aspect of the thigh. This positioning ensures an accurate measurement. Placing the cuff around the ankle (Choice C) or above the knee (Choice D) would not provide an accurate blood pressure reading in the lower extremity. Using a smaller cuff designed for lower extremities (Choice B) is not appropriate as the standard cuff size should be used with the bladder placed over the posterior aspect of the thigh.
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